a 1[DEPARTMENT OF FORENSIC MEDICINE AND TOXICOLOGY AIIMS, NEW DELHI- 29 Cl. FM No18/2014 Dated: 27" Sep. 2014 SUBSEQUENT MEDICAL BOARD OPINION IN THE CASE OF LATE SUNANDA PUSHKAR VIDES PM NO. 77/2014 (total 12 pages) ee Dr. Shashank Pooniya Dr Adarsh Kumar Senior Resident Addl. Professor be Rex" Dr. Sudhir K Gupta 4) Professor & Head = LES peng Sun| AG Ss iia |: Be. 0S. Ae Received by iC... BLADE nacre sc (SHO, Sarojini Nagar, New Delhi)2|DEPARTMENT OF FORENSIC MEDICINE AND TOXICQLOGY AIIMS, NEW DELHI- 29 A.Medico legal Analysis of Medical Treatment records of Late Sunanda Pushkar submitted by 1.0. The medical board perused various medical treatment records/reports submitied by 1.0. from page no 1-211 of Kerala Medical Institute, Dr Dang’s Lab Delhi, Lal Path Lab Delhi, Max Healthcare Lab, Medanta Hospital Gurgaon, AIIMS, New Delhi and Rockland Hospital Delhi. The relevant important findings are as under: Document ne 2 of Dr Rajiv Bhasin dated 22° April 2011 mentions that: ‘The patient i.e. Mrs Sunanda was en Excedrin. The same medicine was recovered from scene of occurrence. and submitted to CFSL by IO as exhibit-3B1 Document no 4-6 Lab report dated 12" Jan 2014 shows: ‘The liver, Kidney, thyroid and hematologic profile wes normal. Urine Glucose-nil; Glucose random (Hexokinase method)- 88mg/dl These parameters are normal and suggest that she was not having Diabetes. Document no 43 Lab report dated 12" Jan 2014 is a whole abdomen sonographic reporymentioning liver, gall bladder, pancreas, kidneys and ureter te be in normal parameter and conclusion given 2s “intra-abdominal solid organs are sonologically normal.” Document no 14 &15 Discharge Summary dated 14" Jan 2014 of Kerala Institute of Medical Sciences mentions that the patient ie. Mrs Sunanda was allergic to penicillin and was hemodynamically stable at the time of discharge from hospital. Document no 16 & 17 of Kerala Institute of Medical Sciences dated 14" Jan 2044 shows Echo -Doppler Report which mention normal size cardiac chambers and nermal valves. Good LY function, no RVWMA, No clots / pericardial effusion. No PAH It suggests that there was no cardiac disease /pathology. Docur tno 31 Endoscopic biopsy! Colonoscopic biopsy report dated 18™Jan 2014 shows acute inflammation and ulceration in ileal mucosa. Document ne 33 Lab report dated 17"Jan 2014 shows that IgA and IgG Antigiiiadin antibodies were negative. Result suggests thet she was not having the celiac disease. Pier “E- hes3|DEPARTMENT OF FORENSIC MEDICINE AND TOXICOLOGY AUIMS, NEW DELHI- 29 Document no 35 Lab report dated 14Jan 2014 shows that MTB-PGR DNA test of Yissues was negative, Result suggests that ske was not having tubercular disease. Document no 37 Lab report dated 12"-21" Jan 2014 shows test report of Lupus Anti Coagulant which reads as follows Partial Thromboplastin Time- 23 sec (normal range); Lupus Anticoagulant; 1-46.7 sec (normal range <45, DRVVT method); Lupus Anticoagulant 2-39.2 sec (normal frange <38, DRVVT method). LAT/LA2 tatio-1.18 (Normal range <1.3) which suggests that she was not having the disease Lupus. Document no 38 Lab report dated 12" -21 Jan 2014 shows test report of Lupus Anti Coagulant which reads as foliows- Anti TTG IgA - 1.8(normal}; Anti Endomyceal Antibody Ig4-negative; Immunoglobulin A- 207 mg/dl (normal). ‘Thesd reports suggest that she was not having the disease Lupus. Document no 38 Lab report dated 12" -21" Jan 2014 shows test report of Lupus Anti Coagulant which reads as follows- Immunoglobulin E- 66.1|U/m! (normal); Immunoglobulin G- 1030 mg/dl (normal). ‘These reports suggest that she was not having the disease Lupus. Document no 40 Lab report dated 12" -21" Jan 2074 shows test report of Lupus Anti Coagulant which reads as follows- Immunoglobulin M- 180 mg/dl (normal); Immunoglobulin D- IgD Heavy Chain- 3.8 %. “These reports suggest that she was not having the disease Lupus. Dosument no 42 of Dr Dangs Lab Pvt Ltd dated 3” Dec, 2013 shows test report of Immune Assays which reads as follows- Ani SM Antibodies (IGG), Anti SS-A Antibodies/RO $2 (IGG), Ant SS-B LA AniibadiesIRO 52 (IGG) — Negative. pheee a ee Ca4|DEPARTMENT OF FORENSIC MEDICINE AND TOXICOLOGY AIIMS, NEW DELHI- 29 Document no 43 of Dr Dangs Lab Pvt Lid dated 5® Dec. 2013 shows test report of immuno Assays which reads as follows- Anti Nuclear Antibody- Negative; Double stranded DNA antibodies- Negative. These reports suggest that she was not having the disease Lupus. Document no 45 of Dr Dangs Lab Pvt Ltd dated 5" Deo. 2013 shows test report of Urine which shows normal macroscopic 2s well as microscopic findings. Document no 46 uf Dr Dangs Lab Pvt Ltd dated 5" Dec. 2013 shows test report of Immuno Assays which reads as- TSH-1.74 ulU/mL( reference value- 0.27-4.20), Serum Vitamin D-3-80.50 ngimL (adequate). Both findings are normal Document no 47 of Dr Dangs Lab Pvt Lid dated 5" Dec. 2013 shows test report of Serology and Immunology which reads as follows- C-reactive protein-0.54 mg/dL, Complement €3-128 mg/d, Complement 4-23 mgfdL Document no 48 of Dr Dangs Lab Pvt Lid dated 5” Dec, 2013 shows test report of Serolpgy and Immunology which reads as follows- Serum Albumin/Globulin-1,67 (normal); Pancreatic Alfa Amylase-50 IU/L (normal CPK-73 U/L(normat) Document no 49 and 50_of Dr Dangs Lab Pvt Ltd dated 6" Dec. 2013 shows test report of Biochemistry and Immunoturbimetry which reads as follows- The liver, kidney, lipid, hematologic profile and blood sugar was normal. Document no. 51-53 of Dr Dangs Lab Pvt Lid dated 23% Sep. 2013 shows test Teport of Drug Assays of Mr Shiv Menon which reads as follows- Opiates, Benzodiazepine & Cocaine Assay as Negative; Cannabinoids Assay as positive, Document no 59 of Dr Dangs Leb Pvt Lid dated'21" Sep. 2013 shows test report of Biochemistry and Immunoturbimeiry which reads as follows- The liver, kidney and blood sugar were normal. Document no 60-64 of Dr Dangs Lab Pvi Lid dated 217 Sep. 2013 shows test report of hormonal fevels which are normal except Progesterone (decreased). Wo hs jeter.a a ne tem nea S[DEPARTMENT OF FORENSIC MEDICINE AND TOXICOLOGY AIMS, NEW DELHI- 28 * Document no 67 of Dr Dangs Lab Pvt Lid dated 21% ‘Sep. 2013 shows test report of "Immuno Assays which shows negative Anti Nuclear Antibody. * Document no. 69 to 74 are of Mr. Shiv Menon * Document no 74 of Dr Lal Path Labs report dated 25° March 2013 shows report of ‘coagulation profile and serum amylase to be normal. ° Document no 75 of Dr Lal Path Labs dated 23" March 2013 shows test report of Immuno Assays which reads as follows- Anti Nuclear Antibody. 3.47 which is normal (Negative <20). + Document no 84-104 of Medants Medicity Hospital, Gurgaon dated 20" December 2011 shows various reports which ate normal except Vit. D (decreased), FSH (increased), HSGRP(increased) and left C5-C6 radicu! lopathy. * Document no 105-106 of Medanta Medicity Hospital, Gurgaon dated 20" December 2011 shows 2D Echocardiography repori which reads as- “No regional wall moticn abnormality. LV/LA are normal. Nomal LV ‘systolic function, LVEF-55%. MV is normal, irece MR. AV is normal. Trace TR, mild AH ( PSAP-42 min Hg).IVG is prominent collapsing < 50% during deep inspiration. No. pericardial effusion seen, No vegetation seen.” * Document no 107 of Medanta Medicity Hospital, Gurgaon dated 20" December ~ 2011 shows report of preclinical atherosclerotic detection which reads as normal. * Document no 114 of Medanta Medicity Hospital, Gurgaon dated 20" December 2011 shows alleged family history of Mother Diabetic, Father suffered CAD, Matemal uncle-brain tumor, brother Brain sancer during routine medical check up. * Document no. 130 te 138 and document no. 151 are of Dr. Sashi Tharoor, * Document no. 146 to 148 of Dr. Lal Path Labs dated 141 June 2012 shows Liver and Kidney function tests in normal limit: however the report shows Vitamin D fo be in insufficient level * Document no. 149 to 150 of Dr. Lal Path Labs dated 11” June 2012 shows result of hemogram to be in normal limit. = Document no. 153 of Max Healthcare Labs dated 6 September 2011 is of Dengue NS 1 antigen test (Elisa), showing negative result. Pee ao Ot6|DEPARTMENT OF FORENSIC MEDICINE AND TOXICOLOGY ALIMS, NEW DELHI- 29 Document no. 154 to 163 of Dr. Lal Path Labs dated 8 August 2011 shows results Of tests for Fasting glucose, Lipid prafile, Urea, Iron studies, FSH and LH levels, LFT, Thyroid profile, RPR) VORL and hemogram, All tests are normal except leucocyte count 11.30 thowlmm? (normal 4-10) in document number 163. Document number 158 & 459 shows FSH and LH te be in post menopausal limit. Document no. 167 and 168 of Dr. Lal Path Labs dated 22 March 2011 shows results of tests for Leucocyte count and electrolytes. All testis ere normal except potassium level 3.40 meg/L (normal 3.50- 5.70) Document no. 475 of Dr. Lal Path Labs dated 30" November 2010 shows results of tests for Anti nuclear antibody. Level of anti nuclear antibody was increased to 20.20 Urmi (ref. range-<10.04). Document no. 179 of Dr. Lal Path Labs dated 2" December 2010 shows results of stool examination to be normal Document no. 180 of Dr, Lal Path Labs dated 2" December 2010 shows results of urine examination to be normal Document no. 182 of Dr. Lal Path Labs dated 11 November 2010 shows results of Iron sfudies, showing reduced iron level and reduced transfetrin saturation. Document no. 183 of Dr. Lai Path Labs dated 5" November 2010 shows results of Lipid Profile, showing increased level of Cholesterol, HDL, LOL and VLDL. Document no. 191 of Dr. Lal Path Labs dated 6" November 2010 shows results of C-reactive protein (hsCRP), showing increased level. Document no. 214 of Rockland Hospital, New Delhi shows negative urine pregnancy test. \f - ee oe {interpretation followed.T[DEPARTMENT OF FORENSIC MEDICINE AND TOXICOLOGY AIMS, NEW DELHI- 29 1. Deceased Sunanda Pushkar did not have any cardiac problem. She was having @ normal healthy heart. . Deceased Sunanda Pushkar was not suffering from Hypertension Deceased Sunanda Pushkar was not suffering from Diabetes Deceased Sunanda Pushkar was net suffering from Tuberculosis. Deceased Sunanda Pushkar did not-have any disease of brain, lungs, liver & kidneys. 6. Deceased Sunanda Pushkar was thoroughly investigated for various autoimmune/connective tissue disorders and was found to be normal. 7. Deceased Sunanda Pushkar Tharoor was thoroughly investigated for Systemic Lupus Erythematosus (SLE); however she was not found to be suffering from LUPUS. Inference of medical documents. Ail above medical documents (211 pages) given by !.0. conclude that deceased Sunanda Pushkar was neither ill nor had any disease prior to her death. She was 2 normal healthy individual.8[DEPARTMENT OF FORENSIC MEDICINE AND TOXICOLOGY AIIMS, -NEW DELHI- 29 8. Reports of Chemical Exatnination of Viscera from CFSL & FSL: The chemical analysis report of CFSL vide No CFSL-2014/C-0098 dated 7” March 2014 (1 page) is positive for ethyl alcohol, caffeine, acetaminophen in viscera and blood. Exhibit 2, having one wet purple colour top of make “Relax, rest Sleep” having very faint off- white stains at six places and one wet purple colour printed lower of make “M & 8", is positive for acetaminophen, caffeine, lidocaine and Methylparaben. FSL report vides Report No. FSL-2014/C-2792 dated 20" Aug 2044 (3 pages) shows presence of ethyl alcohol, caffeine, acetaminophen and cotinine in viscera. However both chemical analysis reports of viscera did not mention the quantity of above chemicals except Ethyl alcohol as 1.8 mg% in blood by FSL Delhi. Inference of Chemical Examination Report of viscer It is positive for ethyl alcohol, caffeine, acetaminophen and cotinine. C. PM Report and Lab findings: Histopathological microscopic examination of slides prepared from heart, brain, liver and spleen are unremarkable. The microscopic examination of both kidneys shows features of acute tubular necrosis. The clinical observation during the post-mortem examination of stomiach showed haemorrhagic patches all over stomach mucosa and stomach was containing 50 mi of chocolate colour fluid. Visceral organs viz. kidney, liver and brain were showing congestion. Both lungs were congested and edematous and white colour froth was coming out on squeezing, Total weight of both iungs was 1100 gms which is about 300 to 400 gms more than normal. The post-mortem examination does not reveal any disease or any pathology except the ante mortem injuries found on the body. Further 10 Insp Atul Sood submitted request letter vide Dy No 1506 dated 28" Aug 2014 PS Sarojini Nagar alongwith FSL & CFSL Report as mentioned above. Following queries were asked by IO: 4. The actual cause of death 2. The nature and duration of each injury mentioned in post-mortem report jury mark mentioned as Injury No 10 in the PI 3. The specific duration o report pleS|DEPARTMENT OF FORENSIC MEDICINE AND TOXICOLOGY ALETMS, NEW DELHI- 28 OPINION OF MEDICAL BOARD: Board thoroughly perused various decuments & reports as submitted by [0 along with PM report and histopathology report of viscera and concluded as below: The cause of death in this case is poisoning. Viscera are positive for ethyl alcohol, caffeine, acetaminophen and cotinine, Medical board reserved the comment on specific poison/ehemical since there is a lot of limitation on viscera report {the detail is attached as annexure 1). Duration of injuries has been opined already. However, the reason of these physical injuries, circumstantial evidences and statements have not been submitted by [O in Spite of letter No CL FM 18/2014 dated 4” April 2014 and the same is required for any further possible medical comments. It is suggested that the following medico-logal points are required to be addressed by IO since the circumstantial information are essential for medical opinion: 4. Photographs of scene of occurrence have not been submitted by 1.0. 2.1 The statements & other circumstantial evidences have not been submitted by LO. 3. There were medicines recovered from scene of incidence ie. hotel room in which the deceased was found dead, Who prescribed these drugs, from where these drugs were procured and for whom these crugs were prescribed? 4. None of the treatment documents of Mrs, Sunanda Pushkar has mentioned Prescription of Tablet Alorax which was found at the scene of dsath. . 5. TWo used Alprax strips of capacity 15 tablets each were nacovered from the crime scene, however viscera repor is negative for presence of Alprazolam. ©. Exhibit 2, having one wet purple colour top of make “Rolex, rest Sleep" having very faint off- white stains at six places and one wet purple colour printed lower of make “M&S, is positive for acetaminophen, caffeine, lidocaine and Methyiparaben - itis a circumstantial evidence and requires further investigation, 7. 10 is advised to enquire whether any close relative of deceased has been prescribed Alprax. 8. Details of any medical conetitation suring hotel etay prior te her death. 9. The statement from doctor who aitended Sunanda Pushkar after death in hotel, 10.Mitd foul smelling gas wes coming out and tache noir was present in left eye. It should be clarified that when was the deceased iasi secn alive. 44. E-mail dated 26™ January 2014 sent by Dr Rajiv Bhasin ( NOIDA) 12. Email dated 12" February 2014 sent by Dr Anil Gupta (Cooper Health Clinic, Dubai. UAE) after death of Mrs Sunanda Pushkar requires investigation 10 establish their speculation about the disease and cause of death 48. Condition of bed sheetimatiress on which Sunanda Pushkar was found dead also requires Forensic analysis, Malo: ee ee kePARTMENT OF FORENSIC MEDICINE AND TOXICOLOGY AILMS, NEW DELHI- 29 10] Annexure-1 From Standard Forensic Literature: In forensic toxicology there are so many reasons due to which poison/chemical may not be detected in viscera test like complete metabolism, excretion, decomposition. inappropriate technique used in detection and the intake of nature of poison beyond the list of common poison. It is possible that a person may die from effects of Poison, and yet none may be found in body after death. If the whole of the poison has disappeared from the lungs by evaporation or has been removed from the stomach and intestines by vomiting and purging, urination and other absorption has detoxified, conjugated and eiiminated from the system by the kidneys and other channels, Certain vegetable poisons mey not be detected in the viscera as they have no reliable tests while some organic poisons especially the alkaloids and glucosides may by oxidation during life or by putrefaction afier death be split up into other substances which have ne characteristic reactions sufficient for their identification. There are ceriain chemical like insulin, potassium chloride, adrenaline if given in fatal dose it may cause death and nothing will be detected in viscera fest. These should be kept in strict confidentiality in the interest of medical ethics and public interest since this medical knowledge going in public may have dangerous effect. 3 The residual analysis of poisons is limited te 10-12 poisons commonly available in the area, The other major killer poisons/chemicais like insulin, KCI, Adrenaline can’t be detected at all in viscera REASONS FOR NON-DETECTION OF POISON IN THE VISCERA 1. Residual analysis only: The procedure followed in our laboratories is of residual analysis of the poisons meaning the actual poisons in their original chemical form are detected and not the metabolites. 2. Substances not detected in routine examination: it is well known that usual routine toxicological screening procedures may not detect hemoglobin like carboxyhaemoglobin, sulphamethemoglobin and methemogicbin. diuretics, solvents, radioactive compounds, antibiotics, non- steroid antiinflammatory substances except aspirin and paracetamol, calcium channel blockers and beta blockers. 3. Lack of suitable chemical tests: If the specific tests are not performed, some poison ray be missed in conventional screening procedures by FSL experts, like Insulin, vegetable poisons, organic poison especially alkaloid and glucosides, bacterial toxins & venoms, potassium Chloride, new substances like buspirone, volatileUL|DEPARTMENT OF FORENSIC MEDICINE AND TOXICOLOGY 40. ALMS,.N vy DELHI- 29 Compounds like aromatic or halogenated hydrocarbons gases toxic anions like thiocyanate, fluoride and nitrites. Fentanyl may have structural dissimilarity from their drug class protutype and give negative results for that particular group. Removal of poisons from the body: The poison has been eliminated from the body due to vomiting, purging. Gaseous or volatile poisoning may be excreted thorough lungs by evaporation. Organic solvent poison gets. evaporated during extraction and concentration. Disintegration of the poison: ‘The poison is metabolized, detoxified, alfered in the body and converts to non- toxic form giving the negative analysis for example detection of phenobarbitone in primidone poisoning, morphine in heroin poisoning, oxazepam in diazepam poisoning, succinyl choline metabolizing to suecinie acid and choline. Haloperidol and oxycolone are also rapidly metabolized. There are many druge, particularly anaesthetic agents containing an ester bond, which are unstable in biological tissues and susceptible to chemical or enzymatic hydrolysis. The treatment given to patient may also aiter the nature of poisonous substance. Decomposition of the tissues It leads to chemical changes in certain poisons. Those paisons are then fendered identifiable by chemical tests e.g. chloral hydrate, sodium nitri cocaine, aconite, atropine ets, Some substances are formed in the tissues by decomposition which gives similar chemical reaction to these obiained from drugs or chemicals such as nelirin, muscarin and mydalein, These reactions may misguide the analyst Volatile substances may be lost as a result of decomposition, There are some drugs which decompose during storage at 40°C like clonazepam, cocaine, isoniazid, methadone, morphine and nitrazepam. Negligible amount of poison in viscera: : The detection of a highly potent poison with a low lethal dose is difficult. Difficult Extraction; The proteinous poisons are rather impossible to extract after absorption in tissues. Similarly, the extraction of water soluble compounds is very difficult. So, ‘they are not detected from tissues by chemical methods of analysis. Caiecholamines like adrenaline gets oxidized when subjected te atmospheric ‘oxygen are, Ascorbic acid and sodium metabisulfite may be Used to avoid this by remaving oxygen from the preservative solution Improper preservation: Ls Leaking Jars, wrong preservative, insufficient quantity of samples, and wrong material of jars are few factors which interferes with the detection of poison, Tampering of the viscera: 3 It may be done during preservation and in preserved bottles with vested interests or wrong motive. Addition of strong chemicals like soap, bleach powder or glutaraldehyde alters the results in immunoassay. Pid" ty GeARTMENT OF FORENSIC MEDICINE AND TOXICOLOGY ALIIMS,.NEW DELHT- 29 POISONS DIFFICULTICAN'T BE DETECTED BY OUR FORENSIC LABS Thallium tis difficult to isolate thallium in bodily fluids. The monovalent thaifium fon, TI", has properties similar to that of the commonly-present sodium and potassium ions, Na" and K" respectively, making identification without a sophisticated instrumental chemical laboratory very difficult. Polonium-240 itis @ rare and highly radioactive isotope. It is hard to detect because all the radiation remains in the body. A lathal dose could be as litile as a few milligrams, which could be administered as a powder or dissolved in liquid/drinks. Nerium oleander ft contains oleandrine glycosides which cross reacts & gives positive results of digoxin immunoassay Snake bites itis net possible to detect the venom by chemical analysis as the venom is destroyed very fast. The ‘no poison’ given by the toxicologist rules out the presence of other poisons in the tissues than snake venom. Snake venom is a Protein and cannot be separated from body tissues. Immunoassay method may detect these poisops but this facility is not easily available in all FSL's. Phatolabile poison Ergot alkaloids, phenothiazines and lysergide are censitive and get decomposed in ‘the light and are not easily identified. Here ‘The heroin: (Diacety! Morphine) is very difficult to detect as it is rapidly hydrolyzedito Monoacetyl morphine and morphine. Ate? ay Dr.'St@shank Pooniya Dr Adaren Kumar esas ee [bs Dr. Sudhir K Gupta Professor & Head